|Original Research (Original Article)|
Eman Alibrahim et al, 2020;4(2):409–416.
International Journal of Medicine in Developing Countries
Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study
Eman Alibrahim1*, Mohanna Al Jindan2
Correspondence to: Eman Alibrahim
*Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia.
Full list of author information is available at the end of the article.
Received: 18 December 2019 | Accepted: 24 December 2019
© 2020 IJMDC. Published by Discover STM Publishing Ltd.
Corneal pathology contributes to 3.5%–9.5% cases of visual impairment in Saudi Arabia, while a significant shortage of corneas that are procured for transplantation is noted. Thereby, this study was conducted to assess the level and determinants of knowledge and attitude regarding corneal donation among the Saudi population.
A cross-sectional study was carried out in the Eastern province of Saudi Arabia from 01 July to 30 September 2018. An electronically administered questionnaire collected socio-demographic data, knowledge (seven items) and attitude regarding corneal donation (seven items). A knowledge score (range = 0–7) was calculated as the number of correct answers. Associations of knowledge score with socio-demographic features and attitude items were analyzed using nonparametric tests.
The study included 1,001 participants with 70.4% females, 42.9% aged 20–29 years, and 69.9% highly educated. The median knowledge score was 2 out of 7, which was higher among females and gradually increased with age (p = 0.016). Attitude showed 28.5% participants were favorable to corneal donation and 21.8% were ready to register as a donor. Non-acceptance of organ separation (44.8%), religion (24.7%), and lack of knowledge (23.6%) were the most frequently reported obstacles to corneal donation. Knowledge level was significantly associated with willingness to donate (p = 0.003), awareness about donation registration procedures (p < 0.001), and readiness to register as a donor (p = 0.004).
Corneal transplantation is not well known among the Saudi population, emphasizing the need for nationwide awareness raising programs, which may increase the number of potential donors.
Cornea, donation, donor, transplantation, knowledge.
Visual impairment represents a major health problem globally. Estimates indicated that approximately 216.6 million individuals were visually impaired in 2015, of which 4.5 million patients experienced moderate-to-severe impairment due to corneal opacity . About 1.5–2 million cases with unilateral visual impairment were reported annually secondary to ocular trauma, infectious keratitis, and corneal opacity . Moreover, corneal disease ranks third among the leading causes of blindness in North Africa and the Middle East after cataract and glaucoma, representing 4.47% of the total cases of blindness among adults . In Saudi Arabia, corneal pathology contributes to 3.5%–9.5% of cases of visual impairment as revealed in population studies [3,4].
Fortunately, about 80% of all corneal-related causes of visual impairment are preventable . These include infectious and traumatic factors. Trachoma is the leading infectious cause and is more predominant in the areas with poor water sanitation, leading to a significant reduction of life expectancy. In particular, visually-impaired young children are more vulnerable to these unfavorable consequences . Therefore, primary prevention is warranted by providing comprehensive eye care services. Besides, corneal transplantation is the mainstay procedure performed for sight restoration in patients with corneal blindness.
Indeed, keratopathy is the most widely performed transplantation procedure worldwide. Corneal transplants have the potential to reduce the global burden of corneal opacity. However, there is a considerable shortage of corneal tissue available for transplantation. In a global survey of the situation of the supply and demand of corneal graft tissue, Gain et al.  showed that more than half of the world’s population had no access to corneal grafts. The situation in Saudi Arabia is even complicated. While the rate of estimated transplantation procedures were 60.3 × 10−6 per capita in 2015, there was a significant shortage of corneas procured per capita (almost estimated as “null”), creating an insufficient procurement balance .
Therefore, the role of eye banking should be stressed in low- and middle-income countries, where the rate of corneal blindness is high coupled with a marked deficiency of donated corneas. Institutions responsible for the collection, processing, and distribution of corneas to trained surgeons are termed eye banks . The expansion of eye banking services would eventually lead to increased keratoplasty procedures. However, eye banking is compounded by multiple challenges, including the increased cost of storage media over long-term periods, unsuitable distribution infrastructure, lack of trained healthcare workers, and sociocultural restrictions associated with organ donation . The latter has affected the concept of donation procedures in general, including corneal transplantation.
As such, the shortage of corneal grafts, as well as the lack of efficient eye banking services, hindered the global efforts aimed at reducing the rates of corneal blindness. Both aspects are also deficient in Saudi Arabia. The first step to address such an issue is to raise public awareness about corneal donation, considering the social and cultural factors. However, little is known about the state of public knowledge, attitudes, and practice of corneal donation in Saudi Arabia. The relevant studies conducted so far were limited to either a specific geographical region  or a distinct population , or used subjective assessment (self-reported) of knowledge . To fill this gap, the present study aimed at assessing the level of knowledge and attitudes regarding corneal donation in the Eastern province of Saudi Arabia. Additionally, the correlation between knowledge and attitude as well as the potential barriers to donation were assessed.
Subjects and Methods
A population-based, cross-sectional study was carried out in several cities of the Eastern province of Saudi Arabia including Al Ahsa, Dammam, Al Khobar, Jubail, and other cities, in the period 01 July to 30 September, 2018. All adult (age>18 years) male and female residents of the target region were included. Individuals having a contraindication to organ donation were excluded.
A semi-structured, self-administered questionnaire was used to collect the following: 1) sociodemographic data, such as age category, gender, and educational level, 2) knowledge about corneal donation such as eye parts concerned with transplantation, time interval between death and cornea removal, inferior age limit for cornea donation, contraindications for cornea donation, etc., 3) attitude regarding corneal donation including willingness to donate, eventual obstacles for cornea donation, awareness about donation registration procedures and readiness to register as donor, etc. A knowledge score (range = 0–7) was calculated as the number of correct answers in the knowledge subscale. The questionnaire underwent face and content validity, and internal consistency of the knowledge subscale was evaluated. The questionnaire was edited and administered electronically via a google form, after being diffused to potential participants using the link sent as a text message.
Statistical analysis was performed with the Statistical Package for Social Sciences version 21.0 for Windows (SPSS Inc., Chicago, IL). Descriptive statistics were used to present the population characteristics as well as patterns of answer regarding knowledge and attitude subscale questions; variables, all being categorical, were presented as frequency and percentage. The reliability of the knowledge subscale was analyzed by calculation of Cronbach’s alpha, along with the analysis of the correlation of correct answering between the different items. A knowledge score (0–7) was calculated as the number of correct answers. Factors of knowledge were analyzed by comparing knowledge scores between the factors’ categories using a Mann–Whitney U test for binomial variables and the Kruskal–Wallis test for multinomial ones. Results were presented as mean, median and 75th centile (P75). A p-value of <0.05 was considered to reject the null hypothesis.
A total 1,001 individuals replied to the questionnaire; majority were females (70.4%), 26% were aged below 20 and 42.6% were aged 20–29 years. The sample was marked by relatively high educational status, as 69.9% had university degree or higher. Distribution of the sample by city showed highest participation from Al Ahsa (57%), followed by Dammam (16.8%) (Table 1).
Of the investigated knowledge items, whether cornea transplantation treated all eye diseases yielded the highest percentage of correct answers (correct answer = no, 40.60%), followed by identification of eye parts concerned with donation (cornea, 36.66%) and whether donor-receiver blood group incompatibility contraindicates cornea transplantation (no, 36.56%). The lowest correctness rate was observed for the time of cornea collection after donor death (1–6 hours, 16.38%). Overall, a high percentage of participants declared having no knowledge about the item (33.97% to 58.54%, depending on the item) (Figure 1).
Table 1. Population’s characteristics.
Distribution of knowledge score showed a left-skewed histogram indicating low levels of knowledge, with a mean score (1.89), standard deviation (1.59), and median score (2.00) (Figure 2).
Reliability testing of knowledge subscale showed adequate Cronbach’s alpha (0.725, seven items), indicating good reliability. However, by considering correct versus incorrect answers, the pair-wise correlations between the different knowledge items were very low with correlation coefficient (r) ranging between 0.060 and 0.278 (Table 2).
Values are represented as Pearson’s correlation coefficient (r). The results showed very low correlation levels between the different knowledge items regarding correct answers; with the best correlation observed between questions 5 and 6 (r = 0.278), followed by questions 1 and 6 (r = 0.223) and questions 1 and 5 (r = 0.220).
Regarding attitudes, only 28.5% of the participants declared being favorable to postmortem corneal donation and 21.8% were ready to register as donors, while 44.9% were not decided yet. Of the total participants, only 6.3% were aware of donation registration procedures and 1.7% only had a donor card. Furthermore, non-acceptance of organ separation (44.8%), religion (24.7%), and lack of knowledge (23.6%) were the most frequently reported obstacles to corneal donation. Among potential donors (those who declared being willing to donate their cornea) and undecided ones, helping rehabilitate other’s sight was the most frequently reported motivation (84.6%), followed by a sense of social responsibility (11.9%) (Table 3).
Knowledge score was higher among females versus males (median=2.0 vs. 1.0; p < 0.001, Mann–Whitney U test) and increased gradually with age (p = 0.016, Kruskal–Wallis test). However, no association of knowledge was found with nationality (p = 0.889), educational level (p = 0.229), and city (p = 0.075) (Table 4).
Participants who declared being willing for the corneal donation had greater knowledge score (mean = 2.15) compared to those who were unfavorable (1.86) or undecided ones (1.74), and the result is statistically significant (p = 0.003, Kruskal–Wallis test). As well, participants who were aware of organ donation registration procedures (2.76 vs. 1.83, p < 0.001, Mann–Whitney U test) and those who declared being ready to donate their cornea (2.17 vs. 1.81, p = 0.004, Mann–Whitney U test) had a greater knowledge score compared to their counterparts, respectively. Donor card owners had greater median knowledge score (2.65 vs. 1.88) compared to their counterparts; however, the result was not statistically significant (p = 0.118; Mann–Whitney U test) (Table 5).
Knowledge levels and attitudes regarding corneal donation have affected the supply of corneal grafts and access to keratoplasty procedures worldwide. It is, therefore, imperative to assess the perceptions regarding these aspects among general populations on a large scale and address the barriers that might impact their willingness to donate. In the present study, it was found that Saudi adults had poor knowledge about corneal donation as indicated by a mean knowledge score of 1.89 (out of 7), while less than one-third of them were favorable to postmortem corneal grafts. About 45% of the participants did not accept the concept of organ separation, including corneas, whereas religious views hindered the willingness to donate in approximately one-quarter of the respondents.
Figure 1. Knowledge about corneal donation and transplantation – Patterns of answers.
The findings of the present study were in agreement with other previously conducted cross-sectional investigations. Bugis et al. , assessed knowledge levels among 681 participants based in the Western region, including Jeddah, Makkah, and Al-Madinah, and demonstrated that only 2.9% of the respondents had good knowledge levels, with a mean score of 7.23 (out of 14). However, higher levels were reported in other countries. For instance, 26.8% of Singaporean youth answered at least 4 out of 7 questions correctly about corneal donation and transplantation . In a community-based study in Northwest Ethiopia, approximately 60% of the participants scored moderate-to-high knowledge on eye donation although only 8.4% had good knowledge . Studies performed on specific populations with health-related backgrounds showed higher knowledge levels. Hameed and Jadidy , revealed higher knowledge levels (35.8%) among medical students of Taibah University. In India, 87% of nursing students had moderate to high knowledge about eye donation. Such a discrepancy is attributable to differences in study designs and the study populations. Therefore, efforts should be exerted to raise public awareness accordingly.
Figure 2. Knowledge about corneal donation and transplantation – Distribution of knowledge scores.
Table 2. Correlation of correctness between the different knowledge items.
Table 3. Attitudes regarding corneal donation (N = 1,001).
§Percentages were calculated among respondents who declared not willing to donate their cornea (N = 267), one participant may report more than one obstacle
¥percentages were calculated among respondents who declared willing to donate their cornea or undecided ones (N = 267).
Indeed, basic knowledge about corneal donation is significantly correlated with the willingness to donate. Wang et al. , found a significantly higher knowledge score in those who were willing to donate as compared to refusers. Willingness to donate was also a significant predictor as repeatedly reported in the literature [13,15]. As such, the knowledge domain should be stressed in future interventions that target promoting corneal transplantation. Besides, the associated factors are to be considered. In current analysis, females had significantly higher knowledge scores, which was consistent with other studies in India . Moreover, females were 1.89 times more likely to answer correct questions than males in a cross-sectional study among 500 Singaporean adults . This could be reflected in the willingness to donate. For example, in an analysis of voluntary Chinese donors, Liu et al.  found that females were more likely to be registered donors. On the other hand, other studies showed that females were reluctant to donate despite the significantly higher knowledge among such a population [16,18]. Such an attitude may be explained by the necessity to get permission from other family members before making a decision. Of note, the impact of gender was not apparent in the knowledge domain in China .
Table 4. Factors associated with knowledge about corneal donation and transplantation.
P75: 75th centile
*statistically significant result (p < 0.05). Tests used: Mann–Whitney U test and Kruskal–Wallis test, as appropriate.
Table 5. Correlation of knowledge with attitude (N = 1,001).
P75: 75th centile
*statistically significant result (p < 0.05).
Older age was another significant factor of knowledge in the present study. Using a logistic regression model, Ronanki et al. , showed that older adults were seven times more likely to be knowledgeable than students in India. Other cross-sectional analyses showed similar findings in India [16,18,19] and Singapore . On the other hand, older Chinese adults tended to be less knowledgeable and were more likely to refuse the donation .
Importantly, Islamic beliefs have remarkably affected the rates of organ and tissue transplantation, including corneal procedures, particularly in the Muslim majority countries. In the present study, religion was an important barrier to donation in one-quarter of the respondents. Actually, religious objections have been consistently reported as nonmodifiable barriers to eye donation [19–21]. Muslims were the least willing to donate as compared to those with other religions in Singapore [13,22], India , and Ethiopia . Likewise, the attitudes of more than two-thirds of an Ethiopian population (of which only 86% were non-Muslims) were favorable to eye donation, and this proportion stated that donation procedures were not against their religious doctrine . Seemingly, enhancing donation-related awareness among such a population might impact their beliefs.
On the contrary, Alanazi et al.  revealed that religious beliefs acted as a common motive for donation and being charitable with the body as indicated by residents of Saudi Arabia in five different regions. The authors suggested the role of Islam to encourage the corneal donation. Bugis et al.  have also found that most of the Muslim participants inherently knew that corneal donation did not contradict the religious beliefs. The majority of Muslim jurists in Egypt have sanctioned obtaining corneal grafts from cadavers of persons who agreed to donate upon death several decades ago . Corneal donation in Saudi Arabia has been studied by the Saudi Department of Research Fatwa and the Saudi Council of Senior Scholars, which sanctioned corneal transplantation in 1978 (Decree No. 66 H1398/1978) . Subsequently, important fatwas have been issued regarding organ transplantation in Saudi Arabia, such that more than 3,600 transplantation procedures have been performed by the end of 2008 . Such information should be heavily emphasized in awareness programs to convince individuals with false beliefs about donation.
However, promoting knowledge should be coupled with increasing the number of available eye banks along with qualified healthcare workers. The eye bank of King Khaled Eye Specialist Hospital is the most active corneal transplant institution, where approximately 1,400 grafts were collected in 2017 . Nonetheless, the majority of grafts were procured from other countries. Additionally, the Saudi Center for Organ Transplantation has contributed to a considerable proportion of corneal transplants although the majority of procedures were related to kidney transplantation . Finally, individuals’ knowledge about the availability of eye banks should be stressed. Previous data showed that a significant proportion of respondents were not knowledgeable about these institutions (97.5%) .
Therefore, it is important to implement efficient intervention programs locally, which would ultimately increase the rates of the corneal donation from deceased persons and promote graft utilization. A non-profit health organization named Sight Life has been established for the purpose of increasing the availability of accessible corneas by facilitating the access to non-used grafts in the United States to be distributed to other demanding areas . Establishing a partnership with such organizations might fill the gap of deficient corneas in Saudi Arabia, providing a rapid solution to the issue until finding a long-term solution by conducting further high-quality eye banks.
The limitations pertinent to cross-sectional studies were also apparent in the present analysis. Variations in understanding and interpreting the questions might affect participants’ answers. This was evident in the low correlation between the different items of the knowledge domain, such that the probability of providing two correct answers by a single respondent was very low (a maximum of 27.8%). Moreover, the confounding factors that could impact the willingness to donate and the perceived myths about the concept of organ and tissue transplantation could not be assessed.
Knowledge about the corneal donation was very low among residents in Saudi Arabia but increased gradually with age with relative gender disparity advantaging females. This was associated with a low proportion of potential donors, as approximately one-quarter of the participants were favorable to corneal donation after death. Non-acceptance of organ separation as well as religious beliefs were significant barriers to donate corneal tissues. The association between increased knowledge about the corneal donation and increased willingness to donate underscores the importance of improving knowledge by conducting relevant nationwide awareness campaigns and educational intervention programs. This would overcome the deficiency of corneal grafts. However, the establishment of new eye banks with highly skilled professionals in Saudi Arabia is warranted to support corneal transplantation procedures.
Conflict of interest
The authors declare that there is no conflict of interest regarding the publication of this article.
Consent for publication
Written consent was obtained from all the participants.
Ethics approval was sought from Imam Abdulrahman bin Faisal University, Jun 3, 2019.
Eman Alibrahim1, Mohanna Al Jindan2
|How to Cite this Article|
Alibrahim E, Jindan MA. Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. IJMDC. 2020; 4(2): 409-416. doi:10.24911/IJMDC.51-1576182666
Alibrahim E, Jindan MA. Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. https://www.ijmdc.com/?mno=77809 [Access: October 15, 2021]. doi:10.24911/IJMDC.51-1576182666
AMA (American Medical Association) Style
Alibrahim E, Jindan MA. Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. IJMDC. 2020; 4(2): 409-416. doi:10.24911/IJMDC.51-1576182666
Alibrahim E, Jindan MA. Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. IJMDC. (2020), [cited October 15, 2021]; 4(2): 409-416. doi:10.24911/IJMDC.51-1576182666
Alibrahim, E. & Jindan, . M. A. (2020) Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. IJMDC, 4 (2), 409-416. doi:10.24911/IJMDC.51-1576182666
Alibrahim, Eman, and Mohanna Al Jindan. 2020. Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. International Journal of Medicine in Developing Countries, 4 (2), 409-416. doi:10.24911/IJMDC.51-1576182666
Alibrahim, Eman, and Mohanna Al Jindan. "Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study." International Journal of Medicine in Developing Countries 4 (2020), 409-416. doi:10.24911/IJMDC.51-1576182666
MLA (The Modern Language Association) Style
Alibrahim, Eman, and Mohanna Al Jindan. "Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study." International Journal of Medicine in Developing Countries 4.2 (2020), 409-416. Print. doi:10.24911/IJMDC.51-1576182666
APA (American Psychological Association) Style
Alibrahim, E. & Jindan, . M. A. (2020) Knowledge and attitude about corneal donation and transplantation in Eastern province: a population-based study. International Journal of Medicine in Developing Countries, 4 (2), 409-416. doi:10.24911/IJMDC.51-1576182666